The sources of vitamin D

Humans obtain vitamin Dfrom dietary sources and supplements, but mainly from sunlight exposure1, 2. Most natural foods contain only small amounts of this fat-soluble vitaminand these quantities are generally inadequate to maintain vitamin D sufficiency. Consequently, the dietary content of vitamin D is usually insufficient to maintain an adequate vitamin D status and cutaneous (skin) synthesis of vitamin D3 on exposure to UVB radiation is essential for vitamin D adequacy, unless fortified foods are eaten or supplements are used3. Thus, if there is insufficient UVB sunlight exposure for adequate cutaneous synthesis of vitamin D, it becomes an essential nutrient4.

Dietary sources of vitamin D include fatty fish, some fish liver oils, organ meats, egg yolks and also fortified foods5, for example certain margarines in South Africa. In Africa, data on dietary vitamin D intake are scarce6. From the little available data on food patterns and sources of intakes of other nutrients, the contribution of dietary sources to vitamin D intake does not seem to be substantial on this continent6. This is primarily because few naturally occurring food sources are rich in vitamin D and in many areas these foods are consumed infrequently or not at all7-9.

Vitamin D obtained from sun exposure, food and supplements is biologically inert and must undergo two hydroxylations in the body for activation. The first occurs in the liver where 25-hydroxyvitamin D (25(OH)D), also known as calcidiol, is formed. The second occurs primarily in the kidney and forms the physiologically active 1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol.

Vitamin D from sun exposure

Solar ultraviolet B (UVB) radiation enters the skin and converts a substance in the skin, called 7-dehydrocholesterol (7-DHC), to previtamin D3, which swiftly converts to vitamin D3 (cholecalciferol), one of the main forms of vitamin D. Excessive solar exposure does not result in vitamin D3 toxicity, as any excess previtamin D3 or vitamin D3 is destroyed by solar exposure10.

Any interference with the penetration of UVB sunlight into the skin and anything that reduces the transmission of UVB sunlight to the surface of the earth will influence the cutaneous synthesis of vitamin D311, 12. Therefore, even with plentiful sunshine, the degree of UVB skin exposure also depends on living and working environments and clothing13 and diets poor in vitamin D can compound risk for vitamin D insufficiency. Sunscreen absorbs UVB radiation and topical application of a factor 15 sunscreen has been shown to absorb 99% of UVB sunlight14. Increased skin pigmentation distinctly decreases vitamin D3 synthesis as eumelanin pigment in the skin competes with 7-DHC for UVB photons and slows the rate of conversion to previtamin D3. People with darker skin require a longer period of time to make sufficient pre-vitamin D315, 16.

Season, latitude and time of day also impact cutaneous vitamin D3 synthesis. The quantity of UVB photons that reach the earth’s surface is affected by the angle at which sun strikes the earth. Only small amounts, if any, vitamin D3 synthesis occurs during winter, early morning and late afternoon, when the zenith angle is increased12, 17. Little or no vitamin D3 can be produced at latitudes above approximately 30 degrees north and south during winter months12. For example, in the southern hemisphere, people living in Buenos Aires (Argentina) and Cape Town (South Africa), can make far less vitamin D from the sun during winter months (June through August) than they can during their spring and summer. In the northern hemisphere, residents in Boston (USA), Edmonton (Canada), and Bergen (Norway) are not able to make enough vitamin D from the sun for 4, 5, and 6 months of the year18.The body stores vitamin D from sun exposure during the summer, but stores must last for many months and by late winter, many people living in these higher-latitude areas are deficient10.

Vitamin D: functions and role in health

The principal physiologic function of vitamin D in humans is to maintain intracellular and extracellular calcium homeostasis in order to ensure its availability for essential functions in bone and dental health. This is achieved through the action of 1,25(OH)2D, the biologically active form of vitamin D, which regulates calcium and phosphorus metabolism in the bone and intestine5, 19. In addition to these well-known effects, more recent research has demonstrated that vitamin D exerts its influence on many physiologic processes. These include modulation of cell growth, neuromuscular and immune function, and reduction of inflammation. Many genes encoding proteins that regulate cell proliferation, differentiation, and apoptosis are modulated in part by vitamin D. Many cells have vitamin D receptors and some convert 25(OH)D to 1,25(OH)2D20. Vitamin D has been associated with a variety of health risks and conditions, including type 1 and type 2 diabetes, hypertension, glucose intolerance and multiple sclerosis20. However, most evidence for the roles of vitamin D in these diseases comes from in vitro, animal and observational studies. Before vitamin D can be recommended as an adjunctive therapy for the treatment or prevention of these diseases, evidence from more rigorously designed clinical trials is needed.

How much vitamin D do we need?

The relative contributions of dietary sources and cutaneous synthesis exposure to UVB sunlight to vitamin D status are still uncertain and this has made it challenging for scientific authorities to establish dietary vitamin D requirements4. It is thus not surprising that a range of authoritative dietary guidelines for vitamin D for specific age groups have been formulated and there is considerable variation in these recommendations21-23.

Very recently, the US DRIs committee for calcium and vitamin D of the Food and Nutrition Board of the Institute of Medicine set an Estimated Average Requirement (EAR) of 10 micrograms (µg) (400 International Units [IU]) and a Recommended Dietary Allowance (RDA) of 15 µg (600 IU) for vitamin D for adults 19 to 70 years20. The previous DRIs for vitamin D included only an Adequate Intake (AI) and Tolerable Upper Intake Level (UL)24. For the establishment of the new recommendations, the DRI committee used evidence of serum25 (OH)D levels that benefited bone health, such as maximising calcium absorption, positive outcomes on bone mineral content and prevention of rickets. However, the committee pointed out that the confounding effect of sunlight exposure has not yet been addressed adequately and advised that it would be ideal if the relative contribution made by sunlight exposure to overall serum 25(OH)D levels could be quantified in formulating the EAR. The committee did, however propose that due to the public health concerns related to sun exposure and skin cancer risk, vitamin D requirements cannot be based on a “recommended” or conventional level of sun exposure20. As is, the committee in establishing the recent EAR and RDA for vitamin D, followed an approach that focused on identifying the vitamin D intakes that will maintain serum 25 (OH)D levels above selected cut-offs when cutaneous synthesis is considerably reduced or absent20.

Measuring vitamin D status

Serum 25-hydroxyvitamin D (25(OH)D) levels is regarded as the best measure of vitamin D status in humans25, 26. While vitamin D deficiency is commonly defined as a 25(OH)D level of less than or equal to 20 nanograms per millilitre (ng/mL), other cut-offs have been used to define vitamin D status and there has been much debate in the literature about optimal serum 25(OH)D levels for the attainment and maintenance of bone mass10, 27, 28. In view of current data, there is some agreement that in adults, vitamin D deficiency is a circulating 25(OH)D concentration of less than 20 ng/mL and vitamin D insufficiency is a 25(OH)D concentration of 20 to 29 ng/mL. Concentrations of 30 ng/ mL and above are considered sufficient10, 12, 29. This is based on data showing that intestinal calcium absorption is maximal above 32 ng/mL30 and that parathyroid hormone levels in adults carry on declining and reach their nadir at between 30 and 40 ng/mL31-33. Other researchers have reported 25(OH)D levels of 32 ng/mL and above as being sufficient34, 35.

Global vitamin D status

Vitamin D deficiency has been found to be widespread in certain subpopulations (using various cut-off points), even among those living in countries with abundant sunshine36, 37. A recent systematic review of the worldwide literature provided a graphical illustration of global vitamin D status38. Areas where data on vitamin D status was lacking included Central America, South America (with the exception of Brazil) and much of Africa. Among adults it was found that in most regions that offer some data, levels of 25(OH)D varied from between 10 and 20 ng/mL and between 20 and 30 ng/mL.

In Africa, seasonal effects on cutaneous synthesis of vitamin D3 would be expected in countries that are located at latitudes greater than 30 degrees north and south, such as South Africa, Egypt, Morocco, Libya, Tunisia and Algeria6. South Africa, especially the country’s southern coast, has a highly seasonal pattern of UVB exposure which affects the potential for cutaneous vitamin D production. An earlier study in Cape Town found only limited vitamin D synthesis in vitro in the winter months from April through to September39. Further studies are investigating vitamin D status and potential impacts of vitamin D nutriture on health outcomes in the southern areas of South Africa40, 41, specifically in relation to infectious diseases.

Early studies showed that dietary saturated fat and cholesterol intake is associated with coronary heart disease (CHD)1. More recent epidemiological studies, however, have shown positive2, inverse3 or no associations4 of dietary saturated fat with CHD mortality and/or morbidity. It should be noted, however, that individual dietary saturated fatty acids do not necessarily affect CHD risk factors equally and that food sources of these fatty acids may also play a role. For example, a diet high in stearic acid (C18:0) does not raise serum cholesterol levels, however, it lowers LDL-C when compared to diets enriched with palmitic (C16:0) or myristic acid (C14:0) and lauric acid(C12:0)5, 6. The hypercholesterolemic effect of palmitic acid is more than that of lauric acid 7. Myristic acid is more hypercholesterolemic than palmitic acid, however, part of the effect may be attributed to an increase in HDL-C7.Additionally, trans fatty acids have clear adverse effects on CHD and should be avoided as far as possible4,8.

A recent Meta-analysis of prospective cohort studies, evaluating the association of saturated fat with cardiovascular disease,found no significant evidence for concluding that dietary saturated fat is associated with increased risk of CHD9. This study further suggested that the historically assumed beneficial effects of diets with reduced saturated fat on CVD risk may be dependent on a significant increase in polyunsaturated fat in these diets due to substitution to keep energy constant between groups in studies9. The WHO/FAO report of an expert consultation even concluded that there is convincing evidence that replacing saturated with polyunsaturated fat decreases the risk of CHD10. Studies often only measure the total amount of saturated fat, monounsaturated fat or polyunsaturated fat in the diet. One should keep in mind, however, that it is becoming clearer in science that even within classification-groups of fat such as polyunsaturated fatty acids (PUFA), sub-groups (i.e.omega-3 PUFA or omega-6 PUFA), specific individual fatty acids or even ratios can cause different effects with regards to coronary heart disease.A recent evaluation of recovered data from the Sydney Diet Heart Study, for example, found that substituting dietary saturated fat with linoleic acid increased the rates of death from coronary heart disease and cardiovascular disease11.Modest increased intakes of long-chain omega-3 PUFA, on the other hand,have been shown to result in pronounced cardiovascular benefits, however, a decreased risk in cardiovascular mortality is probably due to the beneficial effect of omega-3 PUFA on thrombosis or on cardiac arrhythmias rather than on lipoprotein profile12.A meta-analysis of randomised controlled trials onCHD, that considered effects ofspecifically omega-6 fatty acids aswell as a combination of omega-3 and omega-6fatty acids, criticised studies and meta-analyses that advise to substitute saturated fatty acids for omega-6 PUFA rich vegetable oils13. Critique includes oversight of relevant trials with unfavourable outcomes; inclusion of trials with weak design and dominant confounders; failure to distinguish between trials that selectively increased omega-6 PUFA from trials that substantially increased n-3 PUFA; failure to acknowledge that omega-6 and omega-3 PUFA replaced large quantities of trans fatty acids, in addition to saturated fatty acids13.

The message regarding fatty acids and CHD has changed a lot as research evolved. It is important to consider the new research, which has yet again changedthe perspective on fat and fatty acids and coronary heart disease, and to convey the correct message as nutrition experts to the public. It is important to keep in mind that even though saturated fat was not conclusively proven to increase risk, substitution with polyunsaturated fat decreases the risk of CHD, indicating that saturated fat is still a less favourable choice with regards to CHD. One should also acknowledge the differences effects of subtypes of fat as well as individual fatty acids, when making recommendations. Although fat is an important source of energy in the diet, the main message should be to balance energy intake with energy expenditure in an effort to reach and maintain a normal body weight and to ensure that the type of fat consumed promotes health.

Downsizing portions is key to beating obesity

South Africa’s rising obesity epidemic prompted the Department of Health and its partners for National Nutrition Week 2014 to focus this year’s campaign on raising awareness of the importance of portion control.

Statistics show that increasing numbers of South Africans are overweight or obese, with the problem at its worst among adult women and preschool children. Over 40% of adult women are classified as obese and obesity in adult women has increased in the last decade from 27.5% to 40%. In the age group two to five years, 18.9% of girls and 17.5% of boys are classified as overweight. Significantly, over the past decade, the prevalence of overweight preschool boys and girls has risen sharply from 10.6% to 18.2% - an issue which Lynn Moeng, Chief-Director of Health Promotion and Nutrition at the Department of Health says cannot be ignored.

“People are eating too much and they’re eating the wrong foods,” she said. “By educating them about portion size and choices, we aim to change attitudes and habits so that people ‘downsize’ and reduce their health risk.”

‘Eat less – choose your portion with caution!’ will be the central message for National Nutrition Week 2014, with three important supplementary messages, namely:

Choose a variety of foods from different food groups and eat recommended amounts

Make portion control a daily way of life

Use salt and foods high in salt sparingly

Inaugurated 15 years ago, the event is a vital public health intervention and is jointly planned by the Department of Health, the Association for Dietetics in South Africa (ADSA), the Consumer Goods Council of South Africa (CGCSA), the Heart and Stroke Foundation and the Consumer Education Project of Milk SA (CEP). National Nutrition Week 2014 will run from 9 to 15 October.

Research also indicates that the rise in obesity rates have been paralleled by increases in the portion sizes of many foods and the prevalence of eating away from home.

“Eating patterns are likely responsible for an increase in unhealthy weight-gain of the South African population,” said Yolandé van der Riet from the Food Safety Initiative (FSI) division at the CGCSA. “People are eating out more and they’re seemingly eating more energy-dense, processed foods which are high in sugar, fat and salt. People are also eating larger portions of food.”

One research study found that people consumed at least 30% more food due to large portion sizes, including pre-packaged snacks and beverages. The survey also found that people didn’t adjust their intake at their next meal to compensate for having eaten those foods. Another study, the 2008 South African Youth Risk Behaviour Survey, found that around 26.5% of 13-19 year-old learners ate a supersized portion each time they ate fast foods, which van der Riet says highlights the need for widespread public education about portion control and food choices.

However, evidence does show that after education and training, parents are more able to accurately estimate their children’s portion size. “During National Nutrition Week 2014, communications will be aimed at providing the community with practical ways to help them eat less such as using smaller plates, bowls and utensils, repackaging snack foods into individual-sized portions, not eating in front of the television and encouraging children to take a lunchbox containing healthy snacks to school,” says Moeng.

Whilst controlling portion size is an effective, simple, reliable and sustainable tool for weight management, eating large amounts of food is just one of the reasons why people become overweight or obese. Eating high-energy foods that are high in sugar, fat and salt, not eating a variety of foods from the different food groups and not doing sufficient physical activity all lead to weight gain and increased health risks.

As more and more South Africans become overweight or obese, their risk of chronic diseases, diabetes and some cancers increases, said ADSA president, Claire Julsing Strydom.

The 2012 SANHANES report found that two out of five South Africans consumed food low in dietary diversity indicative of a diet of poor nutritional quality, with over a quarter of people consuming a low amount of fruit and vegetables. “We need to create awareness of the importance of eating a variety of foods at each meal – preferably from two or more of the different food groups –and in the recommended amounts according to age, gender and level of physical activity,” she said.

“A high salt intake, which can lead to increased risk of high blood pressure, heart disease and stroke is an additional concern associated with portion distortion,” says Dr. Vash Mungal-Singh, CEO of the Heart and Stroke Foundation SA. The World Health Organisation recommends that adults eat no more than a teaspoon (5 grams) of salt a day from all sources, and although new legislation will limit the salt content of many prepared foods such as bread, awareness of the salt content of foods is crucial, added Mungal-Singh.

“Increasingly more South Africans tend to eat at restaurants and buy fast foods and other processed foods where portion sizes are bigger than normal - and therefore the salt content is higher – whereas they should be choosing a variety of foods from different food groups. The messages of National Nutrition Week 2014 have been carefully chosen to counteract these risky lifestyle habits and to provide South Africans with practical options for healthier choices,” added Maretha Vermaak from the CEP.

“Obesity is a growing crisis and South Africans need a wake-up call about portion control and the importance of regular physical activity before it’s too late,” said Moeng. “The mass communication activities of National Nutrition Week 2014 combined with practical tools such as the South African Guidelines for Healthy Eating and the Food Guide will send a strong public message and give people essential information in accessible and user-friendly formats to help them make long-lasting diet and lifestyle changes. The Government would like to mobilise all South Africans to continue making healthy lifestyle choices”

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“EAT LESS – CHOOSE YOUR PORTION WITH CAUTION”

Facts

Overweight and obesity are affecting the majority of South Africans, especially adult women and preschool children. This is putting South Africans at risk for chronic diseases, such as heart disease and strokes, diabetes and some cancers.

Some of the main reasons why people become overweight or obese are because they are:

(a) Eating large amounts of food (food portions);(b) Eating high-energy foods that are high in sugar, fat and salt;(c) Not eating a variety of food from the different food groups.(d) Not engaging in regular physical activity

Messages about controlling portion sizes

Eat a variety of food at each meal, in other words include foods from two or preferably more food groups at each meal:

Meals should not be high in sugar, fat or salt. Achieve this by not adding extra fat, sugar or salt to your food when cooking or by not buying ready-to-prepare or ready-to-eat meals.

Serve the correct portions of food onto individual plates, instead of putting serving dishes on the table. This will avoid being tempted by second or more helpings.

Use smaller plates, bowls, and serving utensils. Plates with a darker-coloured rim can also help to eat smaller portions, since one will tend to only serve food on the lighter-coloured portion of the plate.

Use a smaller glass to limit the amount of drinks or beverages consumed at a time. Drink lots of clean, safe water.

Keeping excess food out of reach may discourage unintentional overeating. If you don’t buy it you won’t be tempted to eat it.

Be aware that your body may only experience feeling “full” sometime after eating your meal. Therefore, eat slowly, chew properly and pay attention to your body’s internal cues to avoid overeating. Do not eat in from of the TV as this may lead to being distracted and not paying attention to signals of becoming “full” thereby leading to overeating.

Stick to regular meal and evenly-spaced snack times and do not skip meals. This means having small meals (i.e. breakfast, lunch and supper) every day with small healthy snacks in-between if necessary. Vegetable sticks or fruit and low fat of fat free yoghurt or milk are good examples of healthy snacks. Don’t eat too late at night or just before you go to bed.

Encourage children to take a lunch box and healthy snacks such as fruit and yoghurt to school and to avoid buying meals and snacks that are high in sugar, fat and salt.

Many restaurants serve more food than is appropriate for one person. Control the amount of food that ends up on your plate by sharing a meal with a friend or asking the waiter to put half the meal in a “doggie bag” or “take away container”. Alternatively order a salad and a starter as your main meal.

When ordering meals from restaurants, order a small or regular portion size instead of a large portion and have salad or vegetable(s) to complete your meal.

Limit the intake of deep-fried foods and rather choose foods that are steamed, grilled or baked.

Limit the intake of sugar-sweetened beverages (like fizzy drinks and sweetened juices) and replace with unflavoured water, milk, or maas.

Choose healthier low fat, low salt snack options eg: air popped corn. When eating or snacking in front of the TV, put a small amount in a bowl or container and leave the rest of the package in the kitchen.

Snack foods that are bought in bulk should be portioned into individual-sized bags. Store large containers out of sight in a storage closet, cabinet, or garage.

Keeping healthier foods within easy reach means you'll be more likely to eat more of these foods. Place fruit in a large bowl on the counter and serve cut vegetables as the family arrives home from school or work.

Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand

Introduction

The deleterious effect of high salt intake on blood pressure is irrefutable. High salt intake is also associated with gastric cancer and osteoporosis. Data to support the association between sodium and hypertension were generated from animal studies, ecological studies, feeding studies, cohort studies, randomised controlled trials and meta-analyses of such trials. Globally hypertension accounts for 62% of strokes and 49% of heart attacks1,2,3.Norman et al. estimated that hypertension accounted for 9% of all deaths in people 30 years and older in 2000 in South Africa (SA). Of these, 50% of strokes, 42% of ischaemic heart disease, 72% of hypertensive heart disease and 22% of other cardiovascular burden were attributable to high blood pressure4.

Two studies in the United States modelled the impact of salt reduction on population health. Palar and Sturm estimated the effect of salt intakes according to the World Health Organisation (WHO) recommendation of 5g salt per day. Such a decrease would result in an estimated11 million fewer people tobe hypertensive and that 18 billion US dollar less would be spent on health care5. Bibbins-Domingo et al. showed that even if the reduction was as little as 3g of salt intake per day, the number of new cases of coronary heart disease will decrease by 60 000 to 120 000, stroke by 32 000 to66 000 and myocardial infarctions 54 000 to 99 000. Such an intervention would be cost-saving even if only a modest reduction of 1g salt per day were achieved gradually between 2010 and 2019. Reduction of salt intakewould be more cost-effective than using medications to lower blood pressure in all persons with hypertension6.In most populations similar benefits have been predictedif a mean reduction of 1g salt intake per day can be achieved. Salt reduction of 1g per day can save 6000 lives and can prevent a further 6000 non-fatal strokes and heart attacks each year 7.

Global initiatives to reduce salt

In most countries in the world 5 to 18 g of salt per person per day are consumed, which is more thanthe physiological requirement,and has prompted a global movement to support countries to reduce the salt intake of their populations8.Asariaet al. showed that salt reduction is at least as cost-effective as tobacco control9.For this reasonsalt reduction has been identified as a priority intervention and is listed as a cost-effective intervention in non-communicable disease (NCD) prevention10.These influences put salt reduction firmly on the agenda of the UN High-level Meeting on the Prevention and Control of Non-communicable Diseases held in September 2011. At the meeting the WHOwas taskedto develop a global monitoring framework, voluntary global targets and a Global Action Plan for 2013 to reduce the impact of NCDs globally. The target of globally reducing salt intake by 30%, as part of the overall NCD recommendations, was recommended at the WHO Executive Board meeting in January 2013. Once this recommendation was adopted by the member states,all the WHO member states will be in a position to act on high salt intakes in their countries.

Sources of dietary salt in South Africa

Until about 15 years ago very little attention was paid to the amount of salt consumed by South Africans and its impact on their health.Accurately measuring salt intake is challenging, because the gold standard to ascertain salt intake isto measure sodium in all urine passed by a person during a 24 hour period. Conducting such a study in large population studies is not an easy task and few such studies have been conducted in free living populations. In 2005 Charlton et alpublished data on salt intakes of 300 people in Cape Town11. This showed that people of African descent consumed 7.8 g salt per day, while people of mixed race ancestry consumed 8.5g salt and people of European descent had the highest intake at 9.5 g of salt per day.

From a range of nutrition surveys conducted between 1982 and 2010 foods contributing most to salt intake in South African populations were identified.One of the staple foods, namely bread,was the food that contributed the most to salt intake (between 40 -50% of total salt intake). It turned out that South African bread has a remarkably high salt content. Other foodstuffs that contribute significantamounts of saltare meat products like sausage and pies, margarines, gravy and soup powders, meat and vegetable extracts and products containing sodium monoglutamates. These products contribute significantly to the diets of South African low-income groups12.

The benefit of salt reduction in South Africa

These findingspointed to the importance to study the effects of food with less salton blood pressure, especially in low-income groups. Charlton et al. conducted a randomised controlled trial in LangaTownship in Cape Town with the assistance of leading food producers in South Africa12. They manufactured low-sodium versions of six foods, including low-sodium bread,margarine, soup cubes, soup powders, a low-sodium table salt and maas (sour milk) to increase calcium intake. Consumption of the healthier foods compared to the usual commercially produced food significantly reduced blood pressure over an 8-week period.

As salt in South Africa is fortified with iodine a concern has been expressed that salt intake of 5 g or less a day may lead to insufficient iodine intake in geographical areas with low iodine levels. Charlton et al. assessed this and concluded that a salt intake to 5g per day of iodinated salt will not lead to iodine deficiency.13

An economic evaluation of lowering the salt content of bread, soup mix, seasoning and margarine was recently performed in SA. It is estimatedthat by decreasing the salt content in fourfoods by 0.85g/day, the distribution of systolic blood pressure in the South African population would be lowered and would result in 7400 fewer deaths due to cardiovascular disease, as well as 4300 fewer non-fatal strokes per year14. These changes would save SA R300 million annually in direct hospital costs. Stroke is one of the top chronic conditions in terms of cost because of its associated disability. However, the cost saving due to prevention of stroke was not estimated.It was estimated that one-third of the lives saved would be from premature mortality in the under 60 age group.

South African initiatives to reduce salt

The National Department of Health (NDOH)considered the data from international and South African studies,as well as the international movement towards the reduction of salt in food.Theyinitiated aconsultation process withacademics, representatives of the foodindustry and non-governmental organisations such as the Heart and Stroke Foundation of SA. Furthermore, international experts on salt reductionvisitedSA to advise on the process. Guidelines on desirable levels of salt in six groups of foods, from UK, Australia and the USA were consulted to ascertain the target levels of salt agreed to in those countries. A questionnaire was distributed to food industry members and the results showed that about half of the large food industryproducers of products high in sodium preferred to have regulated salt reductions rather than voluntary salt reduction. This is fortuitous as an Australian studyshowed thatmore health gains was seen through mandatory legislative changes on food containing salt than through voluntary changes15. The Minister of Health published draft regulations (R533: 11 July 2012) in the Government Gazette to add to regulations pertaining to the Foodstuffs, Cosmetics and Disinfectants act (act 54 of 1972)16. These draft regulations show how salt will be decreased in certain foodstuffsover a period of several years. These include regulations for the salt content in bread, breakfast cereals, margarines and fat spreads, savoury snacks, processed meats and raw-processed meat sausages, dry soup and gravy powders and stock cubes. Extensive feedback were received over the three months period for comments and the draft regulations were reviewed and adapted to enable a gradual reduction of salt in the identified foods to achieve the required levels well before 2020. The final regulations relating to the reduction of sodium in foodstuffs and related matters were published on 20 March 201317.

It is clear that regulation is only one aspect of the process to ensure an adequate salt reduction strategy for SA. The issue of discretionary salt addedduring domestic food preparation and at the table will require an active and intense public education initiative which is currently being planned in collaboration with the NDOH and the SA Heart and Stroke Foundation. Health professionals and members of the Nutrition Society can play an important role in this initiative.

References:

1. He FJ, MacGregor GA. A comprehensive review on salt and health and current experiences of worldwide salt reduction programmes.J Hum Hypertens 2008;23:363-84.